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II. ХИРУРГИЯ
МРНТИ 76.29.39
ABOUT THE AUTHORS
A. A. Mamedov - Professor, head of the Department .Department of surgery of the liver, biliary tract and pancreas. Scientific center of surgery.M. A. Topchibasheva
Mamedov M. M. - Professor, chief researcher of the Department of surgical Coloproctology. Scientific center of surgery. M. A. Topchibasheva, [email protected] tel +994506616759
Mammadov N. I. - doctor of medical Sciences, doctor of medical Sciences of the Department of surgical Coloproctol-ogy. Scientific center of surgery. M. A.
Topchibasheva, Mamedov V. M. - doctoral student Of the scientific center of surgery. M. A.
Topchibasheva
Alieva A. A.- research associate, Department of endoscopy Of the scientific center of surgery. M. A. Topchibasheva
Keywords
surgical coloproctology,
ileostomy
INDICATIONS AND CHOICE OF PREVENTIVE ILEOSTOMY FOR PLANNED RECONSTRUCTIVE OPERATIONS ON THE COLON
Mamedov A. A., Mamedov M. M., Mamedov N.I., Mammadov V. M., Belyaev A. A.
Scientific center of surgery named after M. A. Topchibashev, Baku, Azerbaijan
Abstract
In the period from January 2016 to November 2019 in the Department of surgical Coloproctology of the Scientific center of surgery M. A. Topchibasheva performed primary recovery operations for the incidence of rectosigmoid rectum with the imposition of colorectal anastomosis with the removal of temporary ileostomy in 51 patients. There were 20 males (39.2%) and 31 females (60.8%). The age of the patients ranged from 34 to 75 years and averaged 63.7± 1.5 years. More than 54% of patients are elderly and senile Patients. the effect of temporary ileostomy prevents the failure of the primary colorectal anastomosis for rectal cancer. In our opinion, a preventive ileostomy should be formed in cases where the risk of anastomosis failure is high. Preventive stomas reduce the incidence of colorectal (coloanal) anastomosis failure and play an important role in preventing complications associated with failure, which significantly expands the possibilities of primary restoration of colonic continuity
АВТОРЛАР ТУРАЛЫ
Мамедов А.А. —
М.А. Топчибашев ат. Гылыми хирургия ортальтшьщ бауыр хирургиясы, ет жолдары жэне уйкы безi 6ел1мшес1нщ мецгерушю/, профессор.
Мамедов М.М. -
М.А. Топчибашев ат. Гылыми хирургия ортальрынын хирургиялык колопроктология бел1мшесшщ бас Fb/лыми кызметкерi, профессор. [email protected]; tel +994506616759
Мамедов Н.И. -
М.А. Топчибашев ат. Гылыми хирургия орталы^ыныц хирургиялык колопроктология 6елiмшесiнiц а.ек., м.ед.
Мамедов В.М. —
М.А. Топчибашев ат. Гылыми хирургия ортальшшьщ докторанты.
Алиева А.А —
М.А. Топчибашев ат. Гылыми хирургия орталыFыньщ эндоскопия 6елiмшесiнiц Еылыми кызметкерi.
Ток ¡шектщ жоспарлы реконструктивтк-калпына келлру операциялары кезшде превентивт илеостоманы тацдау жэне кeрсеткiштерi
Мамедов А.А., Мамедов М.М., Мамедов Н.И., Мамедов В.М., Алиева А.А.
М.А. Топчибашев ат. ?ылыми хирургия орталь™, Баку, Эзiрбайжан
Туйш сездер
хирургиялык колопроктология, илеостома
Ацдатпа
2016 жылдыц кантарынан бастап 2019 жылдыц карашасына деШнп аралыкта М.А. Топчибашев ат. рылыми хирургия орталырыныц хирургиялык колопроктология бел'шшесШде 51 наукаска уакытша илеостоманы шь^ару аркылы колоректалды анастомозды riк iшекriн ректосигмоидты бвлiгiне салу бойынша бастапкы калпына келт'ру операциялары жасалды. Ер адамдардыц саны - 20 (39,2%), эйелдер - 31 (60,8). Наукастардыц жасы 34-тен 75жаска деШнп аралыкта ту,рленп отырды жэне орташа есеппен 63,7± 1,5жастыкурады. Наукастардыц54%-данастамы- егдежэнекэрлкжасынажеткеннаукастар. Уакытша илеостоманын эсер'1 riк iшекriн катерл'1 iсiгiне байланысты салынган бастапкы колоректалды анастомоз дэрменсiздiгiнiн алдын алу€а мyмкiндiк бередi. Б'з превентивт илеостоманы анастомоз дэрменаздшщ пайда болу катер '! жорары болеан жагдайларда €ана калыпrасrыру кажет деген пШрдем'з. Превентивт стомалар колоректалды (колоаналды) анастомоздардын дэрменс'здк жилш темендетед жэне аскынулардын дэрменсiздiгiне байланысты алдын алу шараларында мацызды рел аткарады. Бул ез кезегнде ток iшектiн Yзiлiссiздiгiн бастапкы калпына келтру мYмкiндiкrерiн артты-рады.
Показания и выбор превентивной илеостомы при плановых реконструктивно-восстановительных операциях на толстой кишке
ОБ АВТОРАХ
Мамедов А.А., Мамедов М.М., Maмeдoв Н.И., Мамедов ВЖ, Алиева А.А.
Научный центр хирургии им. М.А. Топчибашева, Баку, Азербайджан
Аннотация
В период с января 2016 по ноябрь 2019 года в в отделение хирургической колопроктологии Научного центра хирургии им.М.А. Топчибашева проведены первично-восстановительные операции по поводу заболеваемости ректосигмоидного отдела прямой кишки с наложением колоректального анастомоза с выведением временной илеостомы 51 больным. Мужчин было 20 (39,2%), женщин - 31 (60,8%). Возраст больных колебался от 34 до 75лет и в среднем составил 63,7± 1,5лет. Более 54% больных - это больные пожилого и старческого возраста Эффект временной илеостомы позволяет предотвратить несостоятельность первичного колоректального анастомоза по поводу рака прямой кишки. По нашему мнению превентивную илеостому необходимо формировать в тех случаях, когда риск возникновения несостоятельности анастомоза представляется высоким. Превентивные стомы снижают частоту несостоятельности колоректальных (колоанальных) анастомозов и играют важную роль в профилактике связанных с несостоятельностью осложнений, что значительно расширяет возможности первичного восстановления толстокишечной непрерывности.
Relevance of the problem
Currently, the problem of treating diseases of the rectosigmoid rectum is still relevant. This is due to a number of factors, the main of which is a significant increase in morbidity and mortality (2,4,9,14). Over the past decades, there has been an increase in the incidence of rectosigmoid rectum all over the world (1,4,5,16). Improving the technique of surgical interventions and anaesthetic support has led to an increase in the proportion of sphincter-preserving operations, which make up to 85% of the total number of performed operations on the rectum (3,6,15). Most authors (7,8,10,11) note the high efficiency of anterior and lower anterior rectal resection in the incidence of rectosigmoid division, which is accompanied by the development of a fairly small number of postoperative complications and rapid recovery of physiological functions of the body. In recent years, there has been a steady increase in the incidence of rectosigmoid rectum. in our country, this localization is becoming the leading one among all neoplasms of the gastrointestinal tract, which is already taking place in many developed countries of the world (3,12,13).
Many patients arrive in a serious condition with complicated forms of the disease, which makes them perform surgical interventions for emergency and urgent indications and complete them with the imposition of various types of colostomy (1.2.5.6.). Currently, restoring the continuity of the colon in
МамедовА.А.-профессор, зав. отделом хирургии печени, желчных путей и поджелудочной железы. Научного центра хирургии им.М.А. Топчибашева
Мамедов М.М.- профессор, главный научный сотрудник отделения хирургической колопроктологии. Научного центра хирургии им. М.А. Топчибашева, [email protected] tel +994506616759
Мамедов Н.И.-д.м.н., с.н.с. отделения хирургической колопроктологии Научного центра хирургии им. М.А. Топчибашева
Мамедов В.М.-докторант Научного центра хирургии им. М.А. Топчибашева
Алиева А.А - научный сотрудник, отделения эндоскопии Научного центра хирургии им. М.А. Топчибашева
Ключевые слова
хирургическая колопроктологя, илеостома
the elimination of colostomy is one of the urgent tasks of abdominal surgery. Removal of ileostomy is a temporary measure designed to solve urgent problems after reconstructive surgery(6,7,18). The majority of patients are people over 50 years of age who have undergone surgery for the incidence of rectosigmoid rectum. However, the incidence of rectosigmoid division is not the only reason for the temporary formation of ileostomy. there are younger patients operated on for non-specific ul-cerative colitis and Crohn's disease, familial intestinal polyposis, diverticular disease, and injuries complicated by intestinal obstruction or peritonitis. (3.5.7.) For most of them, ileostomy is a temporary measure that reduces the risk of anastomosis failure by 100%, and after the closure of the temporary ileostomy, intestinal functions are restored in full. The need to form a temporary ileostomy most often occurs when performing a so-called total coloproc-tectomy in severe Crohn's disease and ulcerative colitis(2,4,11). Modern possibilities of colorectal surgery allow more and more positive solutions to the issue of performing reconstructive operations for patients whose volume of surgical intervention did not previously imply the technical possibility of restoring continuity.(11,17,18) complications in the early postoperative period are No less urgent problem when performing reconstructive operations on the colon. Thus, the failure of anastomosis sutures reaches 6-23% (6.7.8). The clinical expediency and
cost-effectiveness of the use of preventive ileostomy in performing reconstructive operations have been proved.
The aim of the study was to evaluate the role of temporary ileostomy in reconstructive operations on the colon.
Research materials and methods
The work is based on the study of the results of examination of 51 patients who were on inpatient treatment in the Department of surgical Coloproc-tology of the Scientific center of surgery, where they performed extended and combined surgical interventions for the incidence of rectosigmoid rectum with the imposition of primary colorectal anastomosis. Previously, low anterior intersfincter resections with anastomosis and removal of a discharge colostomy (transverzo - or descendostoma) were performed in patients with neoplasms of the middle and lower ampullary rectum. The recovery stage of the operation (elimination of colostomy) during stabilization of the main process, as a rule, was performed through laparotomic access. Since the beginning of 2016, the Department has implemented the imposition of a discharge ileostomy, as a method that is functionally more favorable for the patient in terms of his further rehabilitation. The advantages of this method include the fact that the elimination of ileostomy is technically easier and is performed under intravenous anesthesia from local access. The operation time is reduced by an average of 12-14 minutes. The "disadvantages" include the physiologically determined liquid consistency of fecal masses (thin-intestinal contents) and the associated frequent maceration of the skin in the circumference of the ileostomy.
In the period from January 2016 to September 2019, the Department of surgical Coloproctology performed primary reconstructive operations for the incidence of rectosigmoid rectum with the imposition of colorectal anastomosis and removal of discharge ileostomy in 51 patients. There were 20 males (39.2%) and 31 females (60.8%). The age of the patients ranged from 34 to 75 years and averaged 63.7±1.5 years. More than 54% of patients are elderly and senile. All patients received voluntary informed consent to perform surgery before the operation.
Upon admission to the hospital, all patients underwent a standard set of laboratory and instrumental examinations, the key component of which was computed tomography with intravenous contrast to determine the extent of the process and the involvement of regional lymph nodes. All patients underwent preoperative bowel preparation in the form of antegrade monitor cleaning with fortrans. Mobilization of the left flank of the colon was per-
formed in accordance with the requirements of oncological radicalism, with mandatory preliminary high ligation of the lower mesenteric vessels and lymphodissection in their pool. All operations were completed by applying the primary colorectal anastomosis manually with a single-row and double-row suture with monofilament filaments (vicryl) or using a stapler. A temporary ileostomy was formed from the terminal part of the ileum, at a distance of about 16 cm from the ileocecal angle, removed in the right iliac region and fixed to the skin according to the generally accepted method.
Results and discussion
Indications for preventive ileostomy we consider the presence of tissue infiltration in the pelvic cavity, the anatomical location of the tumor ("under the pelvic peritoneum"), the questionable reliability of the formed anastomosis associated with tension in its zone, as well as the nature of microcirculation in the wall of the colon. It is obvious that the simultaneous restoration of the continuity of the colon after low anterior rectal resections is of fundamental importance. In such situations, based on clinical experience, it is advisable to form a primary anastomosis, despite the risk of its failure, and impose a temporary ileostomy, since repeated reconstructive operations are not always possible.
In our opinion, low anterior resection with total mesrectumectomy with an adequate volume of lym-phodissection is the most optimal and meets modern requirements for the incidence of rectosigmoid rectum. One of the important stages of the operation is the high intersection of the lower mesenteric artery with lymph node dissection in its pool. The postoperative period in three patients (6.4%) was complicated by suppuration of the postoperative wound, in one case (2.1%) developed nosocomial pneumonia, in two patients (4.3%) - antibiotic-associated colitis, which required replacement therapy and correction with probiotics. One patient on day 14 after performing anterior rectal resection with the formation of a temporary ileostomy developed a partial failure of the colorectal anastomosis, which was resolved conservatively by washing the presacral drains with a solution of antiseptics and rational antibiotic therapy. The most likely reason for the failure of the anastomosis was the technical difficulties of applying the anastomosis and changes in the intestinal wall due to microcirculation disorders. In the long-term postoperative period, 3 (5.9%) patients developed maceration of the skin in the circumference of the ileostomy, which was resolved by topical use of medicines and hygienic procedures.
Thus, the effect of a temporary ileostomy can prevent the failure of the primary colorectal anasto-
mosis for rectal cancer. In our opinion, a preventive ileostomy should be formed in cases where the risk of anastomosis failure is high. Preventive ileosto-mas reduce the incidence of colorectal (coloanal)
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